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Illinois Insurance Law update.

  • News
  • Recent Articles
  • New legal decisions help autistic patients
  • New case law on burden of proof in medical benefits litigation
  • comment
  • Mental Parity cases
  • new statute limits coverage
  • General Anesthesia for Dentistry

  • March 15, 2013:
    Petition to restore tax deductions for Autism treatment
    The goal of this petition is to ensure that families with autistic dependents have access to adequate healthcare for treating autism. Health coverage for autism was not included in the Federal Health Care Plan (PPACA), and it was deferred to the States. However, the States have no authority over most self-insured employers and many families are losing their coverage and will not be able to provide care. In addition, Flexible Spending Accounts (FSA) with unlimited levels are very helpful to families with special needs, but these are now limited to $2,500. Many special needs families also fall victim to Alternative Minimum Tax (AMT). Under the AMT, medical bills are generally impossible to deduct effectively. Lack of adequate coverage and these tax repercussions will cause severe economic hardship on families with autism.


    Latest version of Illinois Autism Insurance Mandates, effective Jan. 1, 2013.

    New: Department of Labor expands the Family Medical Leave Act coverage for parents of adult children with disabilities. (Jan. 24, 2013)
            see ADA and FMLA for Parents

    The importance of "Essential Health Services" under the Affordable Care Act.

    Health Care reform could cause the repeal of autism-treatment mandates.

    September 26, 2011.
    In general, the Federal PPACA requires new plans to include Essential Health Services.

    The Act defines certain categories of benefits as "Essential Health Benefits." (Sec. 1302.) 
    The categories of essential health benefits are:

    Congress delegated to the Department of Health and Human Services the task of determining what specific medical benefits qualify under these categories.  Right now, the Department is going through thousands of services which medical providers and patients believe to be essential.  The Department is weighing the costs and benefits of each service.  If the Department issues regulations that allow too many services as required, then the cost of the plans rises, and more employers will drop private plans and direct employees to the exchanges to get insurance.

    Here is the catch.  Where a State mandate adds an entirely new benefit class to qualified health plans sold in exchanges, a state must pay the cost differential for coverage of these benefits. (Sec. 1311.)  In other words, if a service does not qualify as "essential" under the upcoming Federal regulations, but the State mandates the coverage, the State must pay.  Most States today have some autism treatment coverage mandates, including Illinois with the mandate described lower on this page.  If the Federal government fails to find autism treatment such as ABA to be essential, the State will be forced to pay the cost of the program.  You can be sure that revenue-strapped States, especially Illinois which cannot fund its Medicaid program, will quickly drop its autism treatment mandate rather than have to fund it. The Department must issue its regulations in time for plans to be ready for the 2014 effective date.  In making its decision of which benefits are essential, the Department must:
    Let us hope that the Federal government looks at the evidence and the cost of an individual with autism will bear if he does not get early treatment, and rules that behavioural treatment for autism is essential.

    Here is the way out.  On December 16, 2011, the Department of Health and Human Services announced that it would not be issuing a list of essential health benefits.  Instead, it would let the individual States flexibility to select a benchmark plan reflecting the scope of a typical employer plan.  The benchmark would contain the same basket of benefits available from, for example, the largest of small group plans in the State, or the largest State employee plan.  The basket of benefits and services included in the benchmark health insurance plan selected by the State would be the essential health benefits package. Plans could modify coverage within a benefit category so long as they do not reduce the value of coverage.  Since these benchmarks are generally regulated by the State and would be subject to State mandates applicable to the small group market,  those mandates would be included in the State essential health benefits package if the State elected one of the three largest small group plans in that state as its benchmark.  Thus, the State can choose as a benchmark a plan which is subject to the mandates, and the mandates would be included as essential, and then possibly Federally subsidized.  If the State choose a benchmark plan not subject to the mandates, then the mandates would be outside the essential list and the State would have to finance the mandated benefits. 

    Does the HHS solution comply with the law as written by Congress?  We will have to see the final regulations when the HHS issues them. 


    New: Affordable Care Act requires coverage to screen infants for autism

    The Department of Health and Human Services has implemented regulations under the Federal law of 2010, the Affordable Care Act.  This act requires health plans to cover prevention services.  The services must be covered without your having to pay a copayment or co-insurance or meet your deductible, when delivered by a network provider.  Included are many vaccinations, heaing testing, screening for many diseases and
    The complete list for preventive services, adults and children, is http://www.healthcare.gov/law/about/provisions/services/lists.html
    The new regulations start, in general, for plan years commencing after September 2010.  The regulations apply to both insured and self-funded plans, but do not apply to plans which opt out of the new Act if they are "grandfathered" and meet the standards for a grandfathered plan.


    Blue Cross Blue Shield of Michigan settles class-action ABA autism lawsuit
    In denying claims, Blue Cross claimed that behavioral therapy for children with autism spectrum disorder was “experimental” treatment"  But the patients' attorney Mantese said Blue Cross’ own documents showed that the company believes the autism therapy to be a valid treatment.  A draft of a 2005 Blue Cross medical policy stated: “Applied behavioral analysis is currently the most thoroughly researched treatment modality for early intervention approaches to autism spectrum disorders and is the standard of care recommended by the American Academy of Pediatrics, National Academy of Sciences Committee and the Association for Science in Autism Treatment. …”
    http://www.crainsdetroit.com/article/20090619/FREE/906199973#


    October 2008: Congress has passed a bill requiring parity in insurance coverage for  mental-health treatment--
    --Autism Not Included?
    Mental Health Parity

     Illinois law now mandates insurance coverage for Illinois children with autism

    Senate Bill 1900  enacted. November 22, 2008, as part of Senate Bill 934

    Proposed Illinois law would restrict the "habilitation" exclusion. (February 11, 2009)

    Illinois should eliminate the "habilitation" exclusion from health insurance
    Senate Bill 101 as amended


     California Department of Managed Health Care reverses denial of coverage for ABA therapy based on Medical Necessity

    April 24, 2008. The California Department of Managed Health Care provides independent medical review of HMO decisions.  In the Arce decision, the Department reversed the Kaiser Health Plan's denial of coverage for ABA and other therapy for a boy with autism and found the therapy was medically necessary.  The Department relied upon :
    Management of Children With Autism Spectrum Disorders, by Scott M. Myers, MD, Chris Plauché Johnson, MD, MEd the Council on Children With Disabilities. PDF (219 kb)  or Pediatrics link (html) 
    The Department determined that that Arce's request for 10 hours of OT, twice weekly speech therapy, and 20 hours of ABA was medically necessary, and thus Kaiser was bound to cover it. 

    The Illinois Department of Insurance does not provide such review, nor would review apply to self funded plans.  However, the Pediatrics article and the studies it cites may help your appeal or lawsuit for coverage.

    The Pediatrics article (above links) was a survey of different medical interventions and needs of children with autism.  The article included:

    Applied behavior analysis (ABA) is the process of applying interventions that are based on the principles of learning derived from experimental psychology research to systematically change behavior and to demonstrate that the interventions used are responsible for the observable improvement in behavior. ABA methods are used to increase and maintain desirable adaptive behaviors, reduce interfering maladaptive behaviors or narrow the conditions under which they occur, teach new skills, and generalize behaviors to new environments or situations. ABA focuses on the reliable measurement and objective evaluation of observable behavior within relevant settings including the home, school, and community. The effectiveness of ABA-based intervention in ASDs has been well documented through 5 decades of research by using single-subject methodology [fn], and in controlled studies of comprehensive early intensive behavioral intervention programs in university and community settings. [fn] Children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior as well as some measures of social behavior, and their outcomes have been significantly better than those of children in control groups. [fn]
    (emphasis added.)

    California Insurers Balk At Autism Therapy: Switch reason for denying claims

    March 6, 2009: The California department had been sending disputes over the treatment to panels of independent physicians. Increasingly over the last year, those panels had been deciding that the treatments were medically necessary, and the insurers were made to pay.  Then, late last year, Kaiser Permanente, the state's largest nonprofit health insurer, changed its rationale for denying the coverage.  Instead of saying the treatment is not medically necessary, Kaiser now says the therapy is not covered because it is educational and not medical
    http://www.consumerwatchdog.org/patients/articles/?storyId=25146

    California insurer may be barred from denying ABA claims when therapist is not licensed.

    October 27, 2009
    In a preliminary ruling, Los Angeles County Superior Court Judge James C. Chalfant found that Kaiser Permanente's refusal to pay for a child's autism treatment because the provider was not licensed by the state runs counter to California's Mental Health Parity Act. That act requires insurers to cover care for mental and behavioral problems at the same levels they do for physical illnesses.
    http://www.latimes.com/business/la-fi-autism27-2009oct27,0,7328448.story

    New Jersey Court rejects "restorative and non-restorative" exclusion of insurance.  2007

        "In addition, while the Handbook excludes treatment for development of a function or skill beyond that previously demonstrated, there is no definition of "development" or "developmental." Children are constantly developing. "Developmental" defines childhood. The words "restorative" and "non-restorative" when used in this context are also ambiguous and largely inapplicable to infants and young children. Every child is born with the potential to develop those skills necessary to life in society. Autistic children and other children afflicted with BBMIs are hindered from achieving that potential. The treatment for Jake can restore some of his potential. Even with the therapies described, Jake's prognosis is uncertain, but there is no claim that the treatment is futile. To the contrary, there is the expectation that, to some degree, he will share the skills and functions of more fortunate children, including his siblings."
    Micheletti v. State Health Benefits Commission

    New Link: A Blueprint for Parents: Covering ABA through Health Insurance in Indiana
    In July 2001, House Enrollment Act 1122 went into effect as Indiana Code 27-8-14.2, mandating insurance coverage for individuals with Autism Spectrum Disorders for any accident or health insurance policy that is issued on a group basis (large or small). Also, insurers selling individual policies must offer the option to include coverage for Autism Spectrum Disorders (ASD).   This page has good information n how to establish a claim.

    : Illinois should eliminate the "habilitation" exclusion from health insurance


    Tip: when submitting a bill for behavior modification/applied behavior analysis, you can try to use CPT Procedure Code 90808.
    A Diagnosis code that often works for therapy is neuromotor coordination disorder. Some people report that static encepalopathy is an effective diagnosis.

    Doctors should bill for the actual medical symptoms:

    Doctors and therapists should be reminded that they are not treating "autism"...they are treating  related disorders in which autistic symptoms manifest.  They should evidence these diagnoses in the initial evaluation and subsequent visits.   All insurers require medical-service providers to include a diagnosis code (usually called  ICD-9).  The codes should reflect accurate information.  Using these codes is not only more accurate, but also can help avoid insurers that automatically exclude all coverage for autism, either blatantly or under the false exclusion that nothing can help.

    Possibly billable diagnoses involved in autistic symptoms
    Diagnosis ICD-9 Code
    Hypotonia/Dyspraxia 781.3
    Atypical Communication 784.5
    Myoneural disorder (impairment of the sensory organs) 358.8
    hypotonia 784.5
    oral motor verbal apraxia 784.69
    encephalopathy 348.3
    petit mal seizure status 345.2
    Partial Epilepsy, With Impairment Of Consciousness 345.4
    aphasia 784.3
     Nonspecific Abnormal Electroencephalogram (EEG) 794.02
     Abnormal Auditory Perception, Unspecified 388.40

    back to AutismNews


    Articles:

    Study Backs Equal Coverage for Mental Ills

    A new study involving federal employees has found that providing better mental health coverage does not lead to an explosion in insurance costs, a potentially important development in an old national debate over what insurance plans should cover.

    The study, published today in the New England Journal of Medicine, examined seven federal health plans in the years after 1999, when President Bill Clinton ordered companies in the Federal Employees Health Benefits Program to provide coverage for mental health and substance abuse that is comparable to that for other health conditions.

    http://www.washingtonpost.com/wp-dyn/content/article/2006/03/29/AR2006032901861.html?nav=rss_business
    http://www.nytimes.com/2006/03/30/health/30mental.html

    ----------------------------------------

    Medical bills pave way to poorhouse.  Chicago Tribune, February 2, 2005,
    Medical bills may lurk behind about half of personal bankruptcy filings in the United States, according to Harvard University researchers who also found a majority of the debtors they surveyed were middle-class, owned homes and had health insurance at the onset of their illness....For many, health problems set in motion a downward spiral that led to unemployment and subsequently the loss of health insurance; Or, their coverage was filled with so many high co-payments, deductibles and uncovered services that they couldn't pay their bills. Out-of-pocket expenses averaged $11,854 for the medically bankrupt.
    December 2004 New York Times article about trouble getting insurance coverage.
    NYTimesInsurance.html

    This article from the ASA Advocate in 1994, describes one Illinois parent's efforts to make an insurer cover ABA therapy.  TravABA.tif
    (image format, 1683 KB, if it does not open, download and open with Start>Programs>Accessories>Imaging)


    Legal Discussion

    Autism Patient wins court case against Aetna Insurance Co. for coverage for Speech, PT and OT.

    added Aug. 11, 2003.
    The Dr. Chez patient "B" prevailed when the U.S. District Court for the Northern District of Illinois found the insurance company failed to follow the language and terms of the policy.

    The letters justifying the denial of coverage "utterly fail to consider the actual language of the plan at issue here. The letters also largely fail to connect Aetna's denial of benefits to the specific situation and B's diagnosis," the court added.

    Addressing the denial of coverage for speech therapy, the court said there was support in the medical history from which to conclude that autism caused B to lose his previously existing speech skills. Under the plan, speech therapy was covered if a participant had speech function that was lost as the result of a disease, which was expected to be restored by the therapy. The court said Aetna never explained why B did not meet this test.

    Next addressing the denial of coverage for sensory integration therapy, the court found that Aetna failed to make an individualized determination of the possible outcome of the treatment. Instead, Aetna said the effectiveness of the therapy was unproven and therefore, by implication, unnecessary, the court said. In doing this, Aetna "failed to consider the express terms of the plan--the definitions of 'necessary' and 'appropriate,' and it failed to make a rational connection between the particular medical evidence and its conclusion to terminate benefits for this therapy," the court said.

    Also finding that the denial of coverage for occupational therapy was arbitrary, the court said Aetna's explanation that it did not cover long-term occupational therapy for patients with chronic diseases was not based on any language in the plan.

    The court noted the plan was ambiguous regarding the issue of whether developmental delays were covered if they were caused by autism. The court found that the developmental delay exclusion was inapplicable to developmental delays caused by autism, because otherwise the provision for coverage of autism would be meaningless.

    BW case in html (52 kb)
    BWcase in pdf (832 kb, 31 pages)


    Autism is not a mental illness

    Similarly, in 1990, a court ruled that an insurance company could not treat autism as a mental illness for the purpose of its restrictions on mental illness coverages. See Kunin. Kunin is a Ninth Cirucit case directly involving autism. The Seventh Circuit Court of Appeals, which covers Illinois, adopted the Kunin (1992) analysis in Phillips, which was cited by Judge Grady in the 2003 case.  Your situation may differ, but casting your claims as medical rather than mental is important. Since the Illinois staute on serious mental illnesses does not apply the ERISA plans, but only insurance polices, these cases will help.  The Phillips court said:
    The district court questioned Lincoln's definition of "mental illness", reasoning that "aberrant behavioral symptoms are a necessary but not sufficient component of any definition of mental illness" because "[t]here is no question that some conditions are marked primarily by symptoms of dementia and aberrant behavior yet would not be considered mental illnesses. Indeed, under Lincoln's proposed 'unambiguous' meaning of 'mental illness,' an accident victim who exhibits abnormal behavior as the result of a traumatic head injury, a person suffering from brain cancer who develops unusual behavior and an elderly person who has contracted Alzheimer's Disease would all be considered mentally ill. To this list we add a person suffering from a high fever caused by a staph infection who is rendered delirious by his condition. The facts that James behaves abnormally and that he has received medication, psychotherapy and training to modify his behavior do not necessarily mean that he suffers from a mental illness. Those facts do not preclude the possibility that he might be suffering from a physical illness whose symptoms are behavioral."
    Unfortunately, not every case has been favorable.
    A long term disability plan that limited benefits for mental impairments to 18 months did not violate the Americans with Disabilities Act (ADA). This was the ruling of the Second Circuit U.S. Court of Appeals in Fuller v. J.P. Morgan Chase & Co. (No. 03-7829).
    "[W]here the written plan documents confer upon a plan administrator the discretionary authority to determine eligibility, we will not disturb the administrator's ultimate conclusion unless it is 'arbitrary and capricious.'" Pagan v. NYNEX Pension Plan, 52 F.3d 438, 441 (2d Cir. 1995). Under this highly deferential standard of review, this Court cannot substitute its judgment for that of the Plan Administrator and will not overturn a decision to deny or terminate benefits unless "it was 'without reason, unsupported by substantial evidence or erroneous as a matter of law.'" 
    On appeal, the patient had cited her physician's opinion stating that bipolar disorder is a manifestation of "biochemical abnormalities in the brain." Thus, Ms. Fuller argued that bipolar disorder arises from a physical cause within the meaning of the LTD plan, and that she therefore was entitled to benefits until age 65. In rejecting that argument, the Second Circuit stated, "The plan administrator exercised its authority in a plainly reasonable manner by consulting the DSM-IV, an objective authority on the subject of mental disorders, and by relying on that reference work (as it had in the past). It may well be that bipolarity is a manifestation of a chemical or electrical reaction in the brain and that it may be said to arise ultimately from a physical cause. But the issue under the plan wording is whether Fuller's disability 'arises from' a mental disorder, a question quite distinct from whether the disorder itself arises from a physical cause.... Fuller's argument conflates her disability with its underlying cause. Since Fuller's disability arises from a mental syndrome known as bipolar disorder, it is neither arbitrary nor capricious to limit Fuller's benefits, regardless of whether that disorder in turn has a physical cause."
    Similarly, a Federal Court in Illinois ruled in  Rucker v. Regit... Plan, N.D. Ill. 1994, ruled that bipolar disorder was not a mental illness, stating that the issue in its case was not what caused the disorder but whether it was mental.  The different result may arise because of the type of coverage.  In Kunin the issue is the medical condition itself.  Fuller is one step removed, inasmuch as the issue is whether a disability arises from a medical or mental condition.  In another case an insurer lost its argument that depression is a mental disorder, Luton v. Prudential Ins Co America, 88 F. Supp. 2d 1364 (S.D. Fla. 2000).

    Recent cases help define the Burden of proof / Standard of review

    In insurance litigation, the outcome often depends on which party has the burden of proof and which party has the right to interpret the written terms of the plan and the meaning of the medical evidence presented by the patient.  However, recent cases have made the task more difficult.
    [This topic was lengthened and moved to its own page, standard of review.]

    In Mondry v. American Family Mutual Insurance Co., (W.D. Wisc., Nov. 21, 2006) the Plan and Cigna six times stonewalled the participant's efforts to obtain the written plan documents determining when the Plan would cover speech therapy.    Only after lawyers were involved did the plan provide the documents and reverse its denial of the service, which it had initially denied under the habilitation guise.   Similarly, the Sixth Circuit has ruled that the claims determination must be a deliberate, reasoned process. Elliott v. Metro Life Ins. Co.  (6th Cir. 2006):

    New: March 6, 2009: The 7th Circuit Court of Appeals reviewed Mondry, writing
    In particular, nothing in the SPD suggests that  therapy must be “restorative” in order to qualify as “medically necessary.” In short, CIGNA had been relying on [its internal criteria manuals] as the equivalent of plan language, treating the former documents as if they were dispositive and citing them to Mondry as such....
    Because Cigna relied on the documents, ERISA required the Plan to produce them.  The wrinkle was that while Cigna had these secret documents, American Family was the Plan, and it was the Plan's duty, and not Cigna's to deliver the documents.  The court found the Plan liable for statutory penalties for not delivering the documents, suggesting that the Plan should have forced its claims administrator, Cigna, to deliver the documents which showed Cigna's position was wrong. While the documents eventually helped Mondry recover the cost of the speech therapy. the deliver came too late for her to elect COBRA coverage.  Since Cigna misrepresented that speech therapy was not covered, Mondry did not continue the coverage.  The court ruled that ERISA did not provide a remedy for this injury, and that topic is beyond the scope of this article.
    Mondry-7thCir.pdf


    Comment

    Not every case will have the same outcome as BW v. Aetna (above).  Each insurance policy or plan contains different language which controls:  Note also that coverage is easier to prove for regressive autism -- speech therapy is covered for rehabilitation as opposed to habilitation -- that is, to recover what was lost.  (but see note above)

    Most claims are disputed by insurance companies as:

    The enactment of a new Illinois statute (see below) has created a tension in strategies.  Most patients are better off with the general coverages of their health plans.  Autism is technically a syndrome, not an illness since it is defined through its sysmptoms, not its causes.  Autism has physical and organic causes (encephalopathy, epilepsy, gut reaction, etc.) which may manifest themselves with mental symptoms.  (See Kunin and Phillips.)  Since general medical insurance coverage does not have the severe restrictions that restrict mental health coverage (e.g., number of visits or dollar maximums), patients were better off  claiming that autism was not a mental illness.  Now the Illinois legislature has done us a 'favor' by stating that PDD is a mental illness. (See statute following.)  On the one hand, it is good to have some coverage mandated.  On the other hand, will we see insurance companies trying to deny claims under general medical coverages because they can point to the legislature's statute that autism is a mental illness?  You must be vigilant to assure that claims are submitted for a physical diagnosis to avoid the trap.

    The National Conference of State Legislatures has a tracking paper on parity in different States:
    http://www.hpts.org/info/info.nsf/0/8a9e7d91048f8e4985256d0f006f8e8d?OpenDocument
     

    ERISA and Parity

    For the latest news, click Mental Health Parity

    Self-funded health plans - as opposed to insured plans - may be covered under the Federal ERISA laws.  If the company's plan is self-funded, the State statute is preempted and does not apply to the plan.  Daley v. Marriott Int'l, Inc., (8th Cir. 2005) (pdf)  In Daley, an employee sued, arguing claimed that her employer's health plan's limitations of the number of mental health visits for which benefits would be paid (a plan-year maximum of 30 visits and a lifetime maximum of 200 visits) violated Nebraska's State statute mandating mental health parity benefits. This State statute required annual and lifetime limits on mental health benefits to be the same as or better than plan limits on physical health benefits. The Federal Eighth Circuit Court of Appeals held that ERISA preempted Nebraska's mental health parity law as it related to self-funded ERISA plans.  The Federal government did have a limited mental health parity section in the 1996 HIPAA amendments.  Although that part of HIPAA has sunsetted, the Department of Labor has extended its effect through 2005.  29 CFR 2590.712   http://a257.g.akamaitech.net/7/257/2422/14mar20010800/edocket.access.gpo.gov/cfr_2002/julqtr/29cfr2590.712.htm

    The House and Senate passed the Tax Relief and Health Care Bill of 2006 (H.R. 6111, Public Law 109-432), extending the Mental Health Parity Act from December 31, 2006 to the end of 2007 under the Internal Revenue Code, ERISA, and the Public Health Service Act (PHSA). President Bush signed it into Public Law 109-432. The previous extension, H.R. 4579, extended through Dec. 31, 2006, a 1996 law that bans health care plans from offering lower annual and lifetime dollar limits on coverage for mental health conditions than for other medical conditions.

    December 31, 2007  Mental Health Parity Law Extended One Year
    Congress has given final approval to legislation that extends through 2008 the federal law that bans group health care plans from imposing lower annual and lifetime dollar limits for coverage of mental disorders than for other medical conditions.
    The one-year extension of the law, which was set to expire on December 31, 2007, buys time so federal lawmakers can decide whether to expand the parity law to make other plan designs discriminatory. Congress gave final approval to the one-year extension earlier this week.

    This part of HIPAA/ERISA applies to self-funded as well as insured health plans. The old Mental Health Parity part still allows a plan to limit the amount, duration, or scope of mental health benefits under group health plans, except  to lifetime and annual dollar limits. Thus, a plan can still  limit the number of visits which it will cover.

    The Department of Labor has since instituted disability nondiscrimination regulations which may apply in some cases.  The regulations are complex; for example, they would prohibit a plan from refusing to enroll participants with autism into the general medical benefits plan, but the regulations would not prohibit the exclusion of benefits for the treatment of autism itself, so long as the exclusion applied to all members of the plan equally. Similarly, limits on speech therapy which apply to all illnesses would be acceptable.  However, a plan  cannot modify its rules in response to a particular person's claims. See Discrimination in Health Plan Benefit Plans and  29 CFR sec. 2590.702.

    --copyright 2003, 2005, 2006, 2007, 2008 by Frank Stepnowski .


    General Anesthesia for Dentistry for child with disabilities.  see IllDentalIns.html

    New Statute in Illinois requires insurers to cover "serious mental illnesses," including PDD, ASD

    Section 370c Summary:
    a. Nonserious mental conditions
    1. Mandated coverage, but can be limited.
    2. Patient choice of therapists
    3. Referral forms
    b. Serious Mental Illness
    1. shall provide coverage under the policy for treatment of serious mental illness  under the  same  terms  and  conditions  as  coverage  for hospital or medical expenses related to other illnesses and diseases.
    2. List of Seious Mental Illnesses, includes PDDs
    3. Records, timely review, and medical necessity
    4. Mandated coverage - 35 visits

    Actual text:
        (215 ILCS 5/370c)  

    Sec. 370c.  Mental and emotional disorders.

          (a) "Nonserious" mental conditions

    (1)  On and after the effective  date  of  this  Section,  every 
    insurer  which delivers, issues for delivery or renews or modifies group 
    A&H policies providing coverage for hospital  or  medical  treatment  or 
    services  for  illness  on  an expense-incurred basis shall offer to the 
    applicant or group policyholder subject to  the  insurers  standards  of 
    insurability,  coverage  for  reasonable  and  necessary  treatment  and 
    services for mental, emotional or nervous disorders or conditions, other 
    than  serious mental illnesses as defined in item (2) of subsection (b), 
    up to  the  limits  provided  in  the  policy  for  other  disorders  or 
    conditions,  except  (i) the insured may be required to pay up to 50% of 
    expenses incurred as a result of the treatment or services, and (ii) the 
    annual benefit limit may be limited to the lesser of $10,000 or  25%  of 
    the lifetime policy limit. 
            (2)  Each  insured  that is covered for mental, emotional or nervous 
    disorders or conditions shall be free to select the  physician  licensed 
    to   practice   medicine   in   all   its  branches,  licensed  clinical 
    psychologist, licensed clinical  social  worker,  or  licensed  clinical 
    professional  counselor  of  his choice to treat such disorders, and the 
    insurer shall pay the covered charges  of  such  physician  licensed  to 
    practice  medicine  in all its branches, licensed clinical psychologist, 
    licensed clinical  social  worker,  or  licensed  clinical  professional 
    counselor  up  to  the  limits of coverage, provided (i) the disorder or 
    condition treated is covered by the  policy,  and  (ii)  the  physician, 
    licensed  psychologist,  licensed  clinical  social  worker, or licensed 
    clinical professional counselor is authorized to provide  said  services 
    under  the  statutes  of  this  State  and  in  accordance with accepted 
    principles of his profession. 
        (3)  Insofar as this Section applies  solely  to  licensed  clinical 
    social  workers  and  licensed  clinical  professional counselors, those 
    persons who may provide services to individuals shall do  so  after  the 
    licensed  clinical  social  worker  or  licensed  clinical  professional 
    counselor  has  informed  the patient of the desirability of the patient 
    conferring with the patient's primary care physician  and  the  licensed 
    clinical  social  worker or licensed clinical professional counselor has 
    provided written notification to the patient's primary  care  physician, 
    if  any,  that  services  are  being  provided  to  the  patient.   That 
    notification  may,  however, be waived by the patient on a written form. 
    Those forms shall be retained by the licensed clinical social worker  or 
    licensed clinical professional counselor for a period of not less than 5 
    years. 

        (b) "Serious  mental  illness"

    (1)  An  insurer  that provides coverage for hospital or medical 
    expenses under a group policy of accident and health insurance or health 
    care plan amended, delivered, issued, or  renewed  after  the  effective 
    date  of  this amendatory Act of the 92nd General Assembly shall provide 
    coverage under the policy for treatment of serious mental illness  under 
    the  same  terms  and  conditions  as  coverage  for hospital or medical 
    expenses related to other illnesses and diseases.  The coverage required 
    under this Section must  provide  for  same  durational  limits,  amount 
    limits,  deductibles,  and  co-insurance requirements for serious mental 
    illness  as  are  provided  for  other  illnesses  and  diseases.   This 
    subsection does not apply to coverage provided to employees by employers 
    who have 50 or fewer employees. 
        (2)  "Serious  mental  illness"  means  the  following   psychiatric 
    illnesses  as  defined in the most current edition of the Diagnostic and 
    Statistical  Manual  (DSM)  published  by   the   American   Psychiatric 
    Association: 
             (A)  schizophrenia; 
             (B)  paranoid and other psychotic disorders; 
             (C)  bipolar   disorders  (hypomanic,  manic,  depressive,  and mixed); 
             (D)  major depressive disorders (single episode or recurrent); 
             (E)  schizoaffective disorders (bipolar or depressive); 
    >>>  (F)  pervasive developmental disorders; <<<
             (G)  obsessive-compulsive disorders; 
             (H)  depression in childhood and adolescence; and 
             (I)  panic disorder. 
        (3)  Upon  request  of  the  reimbursing  insurer,  a  provider   of 
    treatment  of  serious  mental  illness shall furnish medical records or 
    other  necessary  data  that  substantiate  that  initial  or  continued 
    treatment is at all times medically necessary.  An insurer shall provide 
    a mechanism for the timely review by a provider holding the same license 
    and practicing in the same specialty as the patient's provider,  who  is 
    unaffiliated  with  the insurer, jointly selected by the patient (or the 
    patient's next of kin or legal representative if the patient  is  unable 
    to  act for himself or herself), the patient's provider, and the insurer 
    in the event of a dispute between the  insurer  and  patient's  provider 
    regarding  the  medical necessity of a treatment proposed by a patient's 
    provider.  If the reviewing provider  determines  the  treatment  to  be 
    medically  necessary,  the  insurer  shall provide reimbursement for the 
    treatment.  Future contractual or  employment  actions  by  the  insurer 
    regarding  the  patient's  provider  may  not be based on the provider's 
    participation in this  procedure.  Nothing  prevents  the  insured  from 
    agreeing  in  writing to continue treatment at his or her expense.  When 
    making a determination of the medical necessity for a treatment modality 
    for serous mental illness, an insurer must make the determination  in  a 
    manner   that   is   consistent  with  the  manner  used  to  make  that 
    determination with respect to other diseases or illnesses covered  under 
    the policy, including an appeals process. 
        (4)  A group health benefit plan: 
             (A)  shall  provide  coverage  based upon medical necessity for 
        the following treatment of mental illness in each calendar year; 
                  (i)  45 days of inpatient treatment; and 
                  (ii)  35 visits for outpatient treatment  including  group 
             and individual outpatient treatment; 
             (B)  may  not include a lifetime limit on the number of days of 
        inpatient treatment or the number of outpatient visits covered under 
        the plan; and 
             (C)  shall  include  the  same  amount   limits,   deductibles, 
        copayments,  and  coinsurance  factors for serious mental illness as 
        for physical illness. 
        (5)  An issuer of a group health benefit plan may not  count  toward 
    the  number  of  outpatient  visits  required  to  be covered under this 
    Section an outpatient visit for the purpose of medication management and 
    shall cover the outpatient visits under the same terms and conditions as 
    it covers outpatient visits for the treatment of physical illness. 
        (6)  An issuer of a group health benefit plan may provide  or  offer 
    coverage required under this Section through a managed care plan. 
        (7)  This Section shall not be interpreted to require a group health 
    benefit plan to provide coverage for treatment of: 
             (A)  an addiction to a controlled substance or cannabis that is 
        used in violation of law; or 
             (B)  mental  illness  resulting  from  the  use of a controlled 
        substance or cannabis in violation of law. 
        (8)  This subsection (b) is inoperative after December 31, 2005. 
    (Source: P.A. 92-182, eff. 7-27-01; 92-185, eff.  1-1-02;  92-651,  eff. 
    7-11-02.) 

    New! Effective June 23, 2006:
    Public Act 94-0906 adds the following language:
                (iii) for plans or policies delivered, issued for
            delivery, renewed, or modified after the effective
            date of this amendatory Act of the 94th General
            Assembly, 20 additional outpatient visits for speech
            therapy for treatment of pervasive developmental
            disorders that will be in addition to speech therapy
            provided pursuant to item (ii) of this subparagraph
            (A);

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